What intervention manages failure to descend?

Correct Answer: D

Rationale: Using forceps or a vacuum to assist delivery is the correct intervention for managing failure to descend during labor. When the baby fails to descend through the birth canal despite adequate pushing efforts, it can lead to complications for both the mother and the baby. Forceps and vacuum extraction are tools used by healthcare providers to help guide the baby through the birth canal and facilitate delivery. Administering pain medication, choice A, may provide relief to the mother during labor, but it does not directly address the issue of failure to descend. Pain medication will not help the baby descend through the birth canal. Allowing the patient to rest, choice B, may be beneficial in some cases to allow the mother to regain energy and continue pushing effectively. However, if there is a true failure to descend, simply resting will not resolve the issue and may lead to further complications. Continuing to push for an extended period of time, choice C, can be dangerous for both the mother and the baby. Prolonged pushing without progress can lead to exhaustion for the mother and distress for the baby. It is important to recognize when additional intervention is necessary to ensure a safe delivery. In conclusion, using forceps or a vacuum to assist delivery is the most appropriate intervention for managing failure to descend during labor as it directly addresses the issue and helps guide the baby through the birth canal safely.

Correct Answer: D

Rationale: Monitoring for decreased perfusion is crucial in assessing the adequacy of blood flow to tissues and organs. One way to assess perfusion is by monitoring urine output, making choice D the correct answer. Decreased perfusion can lead to decreased renal blood flow, resulting in a decrease in urine output. Monitoring 24-hour urine output can provide valuable information about the patient's renal function and overall perfusion status. Choice A, monitoring lochia, is not directly related to perfusion. Lochia refers to postpartum vaginal discharge and is more indicative of the healing process after childbirth rather than perfusion status. Choice B, measuring blood loss, can provide information about potential hemorrhage but does not directly assess perfusion. Although decreased blood volume can lead to decreased perfusion, monitoring blood loss alone does not provide a comprehensive assessment of perfusion status. Choice C, checking temperature, can be an indicator of infection or inflammation but does not directly assess perfusion. While infection or inflammation can impact perfusion, monitoring temperature alone is not a reliable method for assessing perfusion status.

Correct Answer: B

Rationale: Ethnicity and religion are important factors for the nurse to note from the prenatal record before proceeding with the physical assessment. Ethnicity can provide valuable information about potential genetic predispositions to certain health conditions or diseases that may impact the pregnancy. Additionally, cultural beliefs and practices related to pregnancy and childbirth can influence the care that the nurse provides to the patient. Weight gain is not necessarily crucial information to note before the physical assessment. While weight gain during pregnancy is important to monitor, it is typically a part of the physical assessment itself rather than a prerequisite for proceeding with the assessment. Age is also not essential information to note before the physical assessment. While maternal age can impact pregnancy outcomes, it is not a prerequisite for conducting a physical assessment. Gravidity and parity are important pieces of information to gather from the prenatal record, but they are not necessary before proceeding with the physical assessment. Gravidity refers to the number of times a woman has been pregnant, while parity refers to the number of times a woman has given birth to a viable offspring. This information is important for understanding the patient's obstetric history, but it is not required before conducting the physical assessment.

Correct Answer: C

Rationale: Leopold's maneuvers are a series of four steps used to assess the position of the fetus in the uterus. Step 1: In the first step, the nurse determines which part of the fetus is located in the upper abdomen. This helps to identify the fetal presentation. Step 2: The second step involves palpating both sides of the uterus to determine which side the fetus's back is on. This helps to determine the fetal position. Step 3: In the third step, the nurse determines the location of the presenting part in the pelvis. This helps to determine the fetal station and engagement. Step 4: The final step involves palpating the lower abdomen to determine the position of the fetal back and limbs. This helps to determine the fetal lie. In this scenario, based on Leopold's maneuvers, if the nurse determines that the fetus's back is on the right side of the mother's abdomen and the small parts are felt on the left side, this indicates a longitudinal lie. A vertical lie means that the fetus's long axis is parallel to the mother's long axis. This is the correct answer. Choice A is incorrect because a transverse fetal position means that the fetus is lying horizontally across the mother's abdomen, which would not be determined by Leopold's maneuvers. Choice B is incorrect because the fetal presentation refers to the part of the fetus that is entering the maternal pelvis first. This is usually determined during the vaginal examination, not by Leopold's maneuvers. Choice D is incorrect because fetal attitude refers to the relationship of the fetal body parts to one another. It is not determined by Leopold's maneuvers, which focus on the position of the fetus in the uterus.

Correct Answer: A

Rationale: In the second stage of labor, the cervix is fully dilated at 10 centimeters and the baby is pushed through the birth canal. Option A, bulging perineum, is a sign that indicates progression into the second stage of labor. This occurs as the baby's head descends and puts pressure on the perineum, causing it to bulge outward. This is a clear indication that the second stage of labor has begun. Option B, increased bloody show, is not necessarily a sign of progression into the second stage of labor. Bloody show is a common sign of labor but it can occur in the first stage as well. It is caused by the release of the mucus plug that seals the cervix during pregnancy. Option C, spontaneous rupture of membranes, is also not a definitive sign of progression into the second stage of labor. This can happen at any point during labor and does not necessarily indicate the beginning of the second stage. Option D, inability to breathe through contractions, is not a sign of progression into the second stage of labor. While contractions can become more intense and frequent in the second stage, breathing techniques can still be used to help manage the pain and discomfort. In summary, the bulging perineum is the most reliable sign that indicates progression into the second stage of labor. Other signs mentioned in the options can occur at various points during labor and are not specific to the second stage.